Provider Demographics
NPI:1972859627
Name:WILKES, FREDDIE EARL JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:FREDDIE
Middle Name:EARL
Last Name:WILKES
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3451 GOODMAN RD E STE 122
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9302
Mailing Address - Country:US
Mailing Address - Phone:662-892-8565
Mailing Address - Fax:
Practice Address - Street 1:2154 GOODMAN RD W # 1
Practice Address - Street 2:
Practice Address - City:HORN LAKE
Practice Address - State:MS
Practice Address - Zip Code:38637-1303
Practice Address - Country:US
Practice Address - Phone:662-392-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.3249122300000X
MS4346-221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist